The following are examples of forms that are used in my day care. Feel free to use them if you like, but please let me know if you do. Thanks
Permission Forms
Registration Form
Child Profile
CARE
Barbara XXXXXX has my permission to seek and obtain emergency medical /dental or surgical treatment as prescribed by a treating physician for my minor child. I give my permission for my child to be transported by car or ambulance to an emergency center for treatment.
Full Name of Minor: _______________________________
Birth Date: _________________________
Allergies to Med.: ______________________
Special Health Problems: _________________
Regular Medication: _____________________
Blood Type ______/ _____
Date of last physical exam:_________________
Name of regular Doctor ___________________________
Name of Insurance Co.: _____________________________
Member/Policy Number: ________________
Name of Policy Holder:________________ Employer: ___________________
WAC 388-150-220 The licensee shall not be responsible for providing or paying for the child's health care. I agree that neither I or my child will bring any claims of any kind against Barb's Little Dumplins Daycare as a result of any injuries, expenses or damages that I or my child may suffer in any way related to the use of our facilities, toys, other children, whether such claims are known or unknown or arise in the future.
Parent/Guardian Signature: _______________________________________ Date:_______________
Barbara XXXXX has my permission to administer over the counter type medication ( Tylenol, Dimetapp, Diaper rash ointment, and Sun block ect. ) to my minor child/children. ________________________ / ____________________________
Parent/Guardian Signature:_________________________________ Date:____________________
Barbara XXXXX has my permission to administer prescription medication to my minor child/children: __________________/_____________________ this being in the original container with the child's name, date prescribed, and dosage on the label.
Parent/Guardian Signature:________________________________ Date:_____________________
Barbara XXXXXX has my permission to transport my minor child/children: _________________/_________________ in her private vehicle. Trips will not be out of the Oak Harbor area without further permission, and each child will be in the appropriate car restraint.
Parent/Guardian Signature:_________________________________ Date:_____________________
Barbara XXXXXX has my permission to:
Take my child/children on a walk Yes No
Take my child /children swimming Yes No
Take photos of my child/children Yes No
Give an occasional candy treat Yes No
Assist my child/children with any toilet training procedures Yes No
Give my telephone number and address to other parents Yes No
Parent/Guardian Signature:_______________________________ Date:________________
Child's Full Name___________________Birth date __________________
Nickname __________________________
Home Address___________________________
Home Phone_________________
Mother's Name___________________________
Occupation __________________
Place of employment ______________________________
Work Phone _________________
Length of employment ________ Estimated date of transfer __________
Cell phone or Beeper _____________
Father's Name ____________________________
Occupation _________________
Place of employment _______________________________Work Phone_________________
Length of employment ________ Estimated date of transfer __________
Cell phone or Beeper _____________
Parent/Guardian with legal custody: _____________________
Parents are: Married /Divorced /Separated / Single
If parents are separated or divorced, please indicate whether the other parent has permission to have contact with the child at Daycare, and whether or not he/she is allowed to pick up the child. If there is a no contact order for the noncustodial parent, I will need to have a copy of the paper work.
Contact: YES NO Pick Up: YES NO NOT APPLICABLE
Emergency Contact Person in addition to parents. They must be within a 20-mile radius.
Name/relationship__________________________Phone___________________
Name/relationship_________________________Phone__________________
Other than you, who has permission to pick up your child? Any persons not listed will not be allowed access to your child. Anyone other than the parents will be required to show photo identification at pick up. Anyone (including parents) should have proper child restraints for transportation.
Name____________________________________Phone_________________
Name____________________________________Phone_________________
Has your child been in day care before? If yes please answer the following. YES ( ) NO ( )
Child's last Daycare Provider information:
Name __________________________ Phone ___________________
Dates attended: from _______________ to _________________
Why was care terminated? _________________________________________________________________
May I contact them for a reference? YES ( ) NO ( )
Parent/Guardian Signature ______________ Date ________________
Date child entered care ______________Date child left care ______________________
Child's Name________________________________________
Age_____________
Has or does your child have any known health problems? YES ( ) NO ( )
If YES describe:____________________________
Does your child need regular medication for the health problem YES ( ) NO ( )
If YES, what and when is it given? _______________________
Please sign the permission forms, authorizing Barb's Little Dumplin's to administer the medication if needed.
Any allergies? YES ( ) NO ( )
If YES, list Allergens:
Special instructions in the event of an allergic reaction:
List communicable diseases your child has had:(Circle those that apply) Chicken pox German measles Measles Mumps Other
Is your child prone to:(Circle those that apply) Stomach upsets Colds Headaches Sore throats Ear aches
Are there any indications of vision or hearing problems? YES ( ) NO ( )
Has he/she had any recent serious illness? YES ( ) NO ( )
Does your child have any mental or physical disabilities? YES ( ) NO ( )
If YES please explain: _____________________
Do you have a back up plan if your child is ill and cannot attend? YES ( ) NO ( )
What is your child's eating habits? (Times child usually eats, mind trying new things) __________________________________________________________________________________________
If your child is drinking formula do they prefer it cold or warm?______________
Child's usual dining habits: (Circle those applicable) HIGHCHAIR TABLE USES UTENSILS BOTTLE SIPPERCUP REGULAR CUPS
Does your child have a small or large appetite?_______________________________________________
Favorite Foods:_________________________________________________________________________
Strong Dislikes:_________________________________________________________________________
Breakfast is served by 7:45 am, will your child eat breakfast before coming to care? YES ( ) NO ( )
How would you describe your child's personality? _______________________________________________
Does your child have a regular bedtime schedule? YES ( ) NO ( )
Does your child have sleep apnea?__________ Night terrors?____________ Walk in sleep?_______________
If infant- how do you prefer your child placed in the crib (front, back, side) ______________
What time do they usually go to bed/afternoon nap? ______________/_____________
What time do they wake in the morning? ________________________
What is their disposition when waking up? i.e. happy, grouchy, clingy, slow________________________
Please list favorite activities:__________________________________________________________________
Please list favorite toys:_____________________________________________________________________
Is your child potty trained YES ( ) NO ( )
Do you wish me to help them with potty training while here? YES ( ) NO ( )
If so, how would you like their training to be approached?_____________________________________
Special instructions concerning care, medications or diet not mentioned above.
Parent/Guardian Signature_______________________ Date________________
